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We welcome your inquiry and look forward to serving your interests. We will be able to serve your interest best if you tell us just a few more things. But if you would rather just talk with us by email or phone, just go to the bottom of this form and hit ‘submit.’ We look forward to being of service to you soon.

Please tell us who you would like to hear from.

	Cordia Senior Residence (Westmont, IL)
	Please tell us if you are: Interested in Cordia for myself Interested in Cordia for a friend or family If you are not interested in our community but wish to contact the Corporate Office, check the box below:
	The Corporate Office (Boston, MA)

What apartment size(s) would be of interest to you? (Check one or more)
studio   one bedroom   two bedroom

When would a move most likely take place?
this month or next   in 2 to 6 months   later than 6 months

What is the reason for thinking of this move to a retirement community? (Check one or more)
want to escape housekeeping, preparing meals and the like
want to find like minded people to spend the days with
need to have someone who can look after day to day physical needs
want to be less isolated, see and do things with people
would like to be able to get out and about without relying on driving or public transportation
Other

Do you have friends that have moved into a senior retirement community?
Yes   No

Use the box below to ask any questions you might have, or to tell us things you think we ought to know in order to serve you better. Use as many words as you need to inform us of your personal circumstances.




How would you like to hear from us? (Check one or all the boxes below)
 Please reply to this e-mail.
 Please mail me information.
 Please call me.

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